Clinical Policy Development Analyst

This is a fully remote position, open to applicants in Florida.

📋 Description

• Investigate emerging laboratory tests, technologies, clinical guidelines, coding modifications, payer policies, and utilization trends.

• Determine and prioritize opportunities for new routine testing policies founded on clinical evidence, market demand, claims data, and potential client benefits.

• Analyze and summarize peer-reviewed research, professional society recommendations, CMS coverage prerequisites, and other authoritative references.

• Compose clinical policies that outline scope, medical necessity criteria, coverage prerequisites, exclusions, limitations, and supporting references.

• Present policy suggestions for clinical evaluation and refine draft policies through the approval and publication process.

• Examine the current policy library for coverage gaps, outdated references, or chances to enhance or consolidate policies.

• Keep organized records of research, citations, decision logs, and version-controlled policy documentation.

• Collaborate with Product, Scientific Affairs, Coding & Translation, and claims-editing teams to facilitate policy implementation and clarify policy intent inquiries.

• Employ authorized AI and large language model tools to aid in research, policy comparison, and evidence synthesis while validating outputs against authoritative sources.

⛳️ Requirements

• Proven ability to assess clinical literature and convert evidence into clear policy language.

• Knowledge of diagnostic testing, medical necessity, and health plan coverage policies.

• Excellent research, analytical, writing, and documentation capabilities.

• Capacity to manage multiple policy-development projects and collaborate effectively across clinical, product, technical, and operational teams.

• Advanced clinical or scientific degree or relevant professional credential (preferred).

• Experience in developing clinical policies for a health plan, laboratory benefit manager, utilization management organization, or healthcare technology company (preferred).

• Understanding of routine laboratory testing, pathology, and diagnostic coding (preferred).

• Familiarity with CMS NCDs and LCDs, commercial payer policies, and professional society guidelines (preferred).

• Experience utilizing claims data or AI-assisted research tools to pinpoint and assess policy opportunities (preferred).

🏝️ Benefits

• Eligible for remote work.

• Quarterly travel required to Avalon’s corporate office in Tampa, Florida.